Outcomes of Upper Arm Arteriovenous Graft vs Brachiobasilic Fistula for Hemodialysis Access

Primary arteriovenous access such as radiocephalic and brachiocephalic fistulas is an initial choice for creating vascular access in dialysis patients. When neither of these choices is an option, upper arm arteriovenous graft or brachiobasilic transposition is recommended. While a primary fistula is better than a prosthetic graft for eligible patients, there is little data available to guide the best treatment strategy in the absence of a suitable vein for primary access creation. This study identifies factors that influence patency rates and compares outcomes of patients treated with a brachiobasilic fistula vs upper arm graft in patients who have failed forearm access or are not candidates for primary access. A prospectively maintained database of patients with dialysis-dependent renal failure from 2010 to 2022 was analyzed. Primary, primary-assisted, and secondary patency rates were calculated. Incidence rates of complications and reinterventions were compared. There were 155 patients with brachiobasilic fistulas and 82 patients with upper arm grafts. The graft group was older (70.1 ± 15.5 vs 63.1 ± 14.7 years, P = .0005) and had a higher incidence of pacemakers (13.4% vs 3.2%, P = .005). Brachiobasilic fistulas had higher 6-month primary-assisted patency (77.4% vs 65.9%, P = .05), but secondary patency rates were better for upper arm grafts at 6 and 12 months (87.8% vs 76.8%, P = .05; 81.7% vs 70.3%, P = .05) with no statistically significant difference at 2 years (67.1% vs 54.2%, P = .07). Access complications of nonmaturation and aneurysm were higher in basilic vein transposition (17.4% vs 1.2%, P < .0001; 18.1% vs 6.1%, P = .01). Grafts had higher rates of occlusion (54.9% vs 26.5%, P = .001). In terms of interventions, upper arm grafts had higher rates of thrombectomy (37.8% vs 6.5%, P < .0001), but there was no difference seen in angioplasty/stent, surgical revision, or procedures for steal syndrome. Basilic vein transpositions had a longer time to cannulation (87.5 vs 31.6 days, P < .0001) and a higher number of procedures to aid maturity (0.5 vs 0.09, P < .0001). In this retrospective analysis, when forearm access or primary arteriovenous access is not an option, basilic vein transposition and upper arm grafts have fairly equivalent primary-assisted patency with slightly worse secondary patency rates in fistulas compared with arteriovenous grafts. Basilic fistulas also had a longer time to cannulation and more procedures to aid maturity.Table IPatients' characteristicsBasilic vein transpositionUpper arm graftP valueNo. of patients15582Sex.01 Female60 (38.7%)45 (54.9%) Male95 (61.3%)37 (45.1%)Age, years63.1 (14.7)70.1 (15.5).0005Race and ethnicity Native American1 (0.6%)0 (0%)1.0 Asian11 (7.1%)7 (8.5%).79 African American67 (43.2%)28 (34.1%).21 Hawaiian/Pacific Islander1 (0.6%)0 (0%)1.0 White76 (49.0%)47 (57.3%).27 Hispanic/Latino34 (21.9%)15 (18.3%).61BMI, kg/m236.4 (6.5)27.5 (8.6).83Comorbidities Diabetes81 (52.3%)47 (57.3%).50 Hypertension131 (84.5%)74 (90.2%).24 Coronary artery disease78 (50.3%)47 (57.3%).34 COPD1 (0.6%)7 (8.5%).0005 Congestive heart failure17 (11.0%)15 (18.3%).16 Atrial fibrillation146 (94.2%)78 (95.1%)1.0 HIV147 (94.8%)79 (96.3%).75 Pacemaker5 (3.2%)11 (13.4%).005 History of cancer17 (15.5%)13 (19.4%).54 Prior failed kidney transplant11 (7.1%)6 (7.3%)1.0 Primary vascular access99 (66.0%)44 (55.0%).11 Prior catheter use97 (62.6%)54 (65.9%).67Total catheter days467 (733.3)342 (619.6).003BMI, Body mass index; COPD, chronic obstructive pulmonary disease.Categorical variables are presented as number (%), and continuous variables are presented as mean (standard deviation). Open table in a new tab Table IIComplications, interventions, and patencyComplicationBasilic vein transpositionUpper arm graftP valueInfection14 (9.0%)8 (9.8%).81Bacteremia25 (16.1%)11 (13.4%).70Stenosis79 (51.0%)40 (48.8%).78Central venous stenosis25 (16.1%)13 (15.9%)1.0Failure to mature27 (17.4%)1 (1.2%).0001Occlusion41 (26.5%)45 (54.9%).001Aneurysm28 (18.1%)5 (6.1%).01Pseudoaneurysm16 (10.3%)5 (6.1%).34Hematoma16 (10.3%)8 (9.8%)1.0Rupture7 (4.5%)5 (6.1%).75Steal and distal ischemia10 (6.5%)3 (3.7%).55Superficialization8 (5.2%)3 (3.7%).75Intervention Angioplasty69 (44.5%)43 (52.4%).27 Stent8 (5.2%)9 (11.0%).11 Thrombectomy10 (6.5%)31 (37.8%)<.0001 Surgical revision20 (12.9%)10 (12.2%)1.0 Steal procedures2 (1.3%)1 (1.2%)1.0 Ligation11 (7.1%)5 (6.1%)1.0Time to cannulation, days87.5 (63.2)31.6 (56.2)<.0001No. of procedures to aid maturity0.5 (0.66)0.09 (0.28)<.0001No. of procedures until access abandonment2.6 (1.9)2.6 (2.1).94Primary patency 6 months79 (51.0%)44 (53.7%).78 1 year62 (40.0%)33 (40.2%)1.0 2 years46 (29.7%)21 (25.6%).55Primary-assisted patency 6 months120 (77.4%)54 (65.9%).05 1 year108 (69.7%)49 (59.8%).15 2 years80 (51.6%)39 (47.6%).58Secondary patency 6 months119 (76.8%)72 (87.8%).05 1 year109 (70.3%)67 (81.7%).05 2 years84 (54.2%)55 (67.1%).07Categorical variables are presented as number (%), and continuous variables are presented as mean (standard deviation). 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